Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock.

BACKGROUND: Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival. METHODS: We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less. RESULTS: Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index). CONCLUSION: Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy. LEVEL OF EVIDENCE: Therapeutic, level II.

Management of anticoagulation with rivaroxaban in trauma and acute care surgery: Complications and reversal strategies as compared to warfarin therapy.

BACKGROUND: Rivaroxaban has gained popularity as an anticoagulant (AC) for stroke prevention in nonvalvular atrial fibrillation (afib) and venous thromboembolism (VTE). Although adverse bleeding events are associated with all AC, lack of point-of-care testing to measure the effect of rivaroxaban in emergent situations has contributed to perceived increased risk among physicians. METHODS: This study aims to describe a single-center experience with trauma and emergency general surgery (EGS) patients taking rivaroxaban and evaluate outcomes compared with patients taking warfarin using a propensity score analysis. Trauma and EGS patients taking rivaroxaban or warfarin for afib/VTE over a 2-year period were eligible for inclusion and matched for injury/illness severity in a 1:2 ratio using propensity score matching. In a single quaternary referral center, 192 warfarin patients were matched to 96 rivaroxaban patients. Groups were well matched with no significant difference in age/sex, admission systolic blood pressure/heart rate, admission hemoglobin, injury severity score (trauma patients), or need for ICU admission. Conditional logistic regression determined association of AC type with bleeding complications, adjusting for age/sex, AC indication, coagulation laboratory values, antiplatelet medications or other AC, comorbidities, renal impairment, and operative intervention. Primary outcome was bleeding complications, defined as hemorrhage during admission or as a presenting problem. Secondary outcomes included invasive interventions, AC reversal, VTE complications, and mortality. RESULTS: There was no difference between rivaroxaban and warfarin for bleeding complications (37% vs. 39%, p = 0.49), VTE complications (4.2% vs. 5.7%, p = 0.44), or mortality (4.2% vs. 5.8%, p = 0.63). Fewer rivaroxaban patients underwent surgical or interventional radiology procedures during admission (32% vs. 43%, p = 0.01), but there was no difference in procedures specifically for bleeding (10% vs. 12% p = 0.68). Rivaroxaban patients less frequently underwent AC reversal (34% vs. 46%, p = 0.01) or received multiple reversal agents (20% vs. 29%, p = 0.02). Regression analysis confirmed AC type was not associated with bleeding complications (rivaroxaban vs. warfarin relative risk 1.02; 95% CI 0.85-1.22, p = 0.85). CONCLUSION: Reversal of rivaroxaban was less common and required fewer agents, whereas bleeding complications and hemostatic interventions do not seem to be different between these AC types. LEVEL OF EVIDENCE: Therapeutic study, level II.